Emerging Advances In Treating Great Toe Arthritis

Babak Baravarian, DPM, FACFAS

One of the most common presenting problems in foot and ankle practices is hallux limitus/rigidus. While destructive procedures were favored in the past to treat this condition, it is now becoming increasingly common to use reconstructive procedures. Accordingly, let us take a closer look at some of the emerging advances in the treatment of great toe arthritis.

   The typical patient presenting to my office with such a problem is a middle-aged man or woman who is active and has developed pain and limited range of motion of the great toe. I try not to use grading systems in such cases because I think it limits my ability to think of each individual and his or
her common needs. Instead, I prefer to break patients out according to lifestyle, gender and the amount of arthritic changes.

   To begin with, the level of arthritis is the most concerning and pressing issue. If the level of arthritis is low, joint destruction is not necessary whereas severe arthritis cases require joint replacement or fusion as a common type of surgery. It may be deceiving to consider a fusion as the only option if there is limited motion as large spurs can limit motion without severe joint destruction. The general point to remember is the longer the time with pain and symptoms, the greater the chance of increased joint arthritis. Women require a greater range of motion than men. Most women prefer to be able to wear heels while this is not a common concern in men.

   Finally, be careful to find out what activity a patient prefers. A man may do yoga and require motion of the great toe, which will not do well with a fusion if avoidable. A woman may love to dance on her tiptoes and cannot do this with a fusion. Conversely, a woman may like to run trails and be very harsh on her feet. This patient may require a fusion to avoid breakdown and further surgery.

   After making the decision for surgery, appropriate adjunct testing is required. Use standard radiographs to check the level of joint destruction, the amount of joint space narrowing and the spur locations and size. If there is concern of sesamoid damage and signs of arthritis of the sesamoid complex are present, I have begun to get a magnetic resonance image (MRI) of the forefoot to check the sesamoid complex for arthritic changes and damage to the articular surface of the plantar metatarsal complex. This is essential in simple spur removal cases or reconstructive cases as increased range of motion may result in greater pain in the arthritic sesamoid complex, which is now moving but did not move before. By getting a MRI, I allow the patient to consider destructive procedures from the start versus knowing the potential for sesamoid pain in reconstructive cases involving sesamoid arthritis.

What You Should Know About Conservative Treatment

Conservative care of great toe arthritis has a solid place in patient care. However, it is essential to consider warning the patient that even the best conservative care will still result in continued destruction of the joint, which may require more advanced and sometimes more destructive procedures in the future. Although I am a fan of conservative care, at times I will try to make the patient understand that short-term pain relief from a conservative option may not be the best long-term answer.

   My best conservative option recently has been a rocker bottom, stiff soled shoe. With the increase in rocker bottom style tennis shoes from several companies, this has become a “cool” option among patients. When it comes to women’s dress shoes, I prefer that patients use a wedge stiff soled shoe that will not allow forefoot motion. For men’s dress shoes, I prefer a very stiff soled leather shoe and shy away from rubber soles. In general, a tennis or basketball shoe is stiffer than a running shoe.

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